New Client Forms

Forever Bare Electrolysis

New Client Forms
Date:*

MonthDayYear
Date
Name/Preferred Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How did you find Forever Bare Electrolysis?*
If referred, who referred you?
Have you had electrolysis before ?*
Are you currently under a physician's care?*
If yes, for what reason?
Are you currently taking any prescribed medication?*
If yes, please list.
Are you currently taking any oral or topical medications like Accutane, Retin-A, or other retinoids for your skin? *
Do you regularly get Botox, fillers, facials, or other skin treatments?*
Do you wax, tweeze, or thread the area ?*
If so, how often?
Have you had laser treatments?*
If so, when was your last treatment?
Please check the area or areas you are interested in treating.*
Do you have or take any of the following? If yes, please check the box.*

Forever Bare Electrolysis